LONDON â€” Americans are "much sicker" than the English, or so it would seem from a comparison of national health surveys.

Action Points

Explain to patients who ask that the apparent health disparities between the English and Americans can not be explained completely by lifestyle factors or differences in government-funded health care between the two countries.

LONDON, May 2 â€” Americans are "much sicker" than the English, or so it would seem from a comparison of national health surveys.

Even the healthiest Americans â€” those at the highest income and education level â€” had rates of diabetes and heart disease similar to the least healthy in England, said Michael Marmot, M.D., of University College London here in the May 3 issue of the Journal of the American Medical Association.

But the reasons behind the seeming English-American health disparity remain a mystery. The differences were not explained by lifestyle factors, such as the American tendency to obesity or the English tendency to drink more heavily. The apparent health gap also wasn't explained by cultural differences affecting self-reporting of disease, Dr. Marmot and colleagues said.

Differences in government health care programs may be a factor, but they do not completely explain the disparity, the investigators said. And gaps in per-capita health care spending don't account for the phenomenon, as Americans spend about twice as much annually as the English ($5,274 versus $2,164, both in U.S. dollars).

The investigators analyzed representative samples of people ages 55 to 64 using data from two surveys designed to have directly comparable measures of health, income, and education. Data on more than 4,300 Americans came from the 2002 U.S. Health and Retirement Survey, and data on more than 3,600 English were obtained from the 2002 English Longitudinal Study of Aging.

Overall, rates of self-reported disease were consistently and significantly higher among Americans than the English (P

Diabetes: Americans: 12.5%, English: 6.1%

Hypertension: Americans: 42.4%, English: 33.8%

All heart disease: Americans: 15.1%, English: 9.6%

Myocardial infarction: Americans: 5.5%, English: 4%

Stroke: Americans: 3.8%, English: 2.3%

Lung disease: Americans: 8.1%, English: 6.3%

Cancer: Americans: 9.5%, English 5.5%

For both Americans and the English, disease rates tended to be higher in the lower socioeconomic groups. However, in many cases, disease rates for Americans in the highest socioeconomic group were comparable to rates in the lowest English group. For example, the rate of heart disease was 12% in the highest American group, compared with 11.6% in the lowest English group.

To see whether these differences might be caused by cultural differences in self-reporting disease, the investigators also examined data from an English and American survey that included clinical measurements of risk for heart disease and stroke, such as C-reactive protein, fibrinogen, and HDL cholesterol levels.

Data from more than 2,000 middle-age Americans from the U.S. National Health and Nutrition Examination Survey (NHANES) and 5,500 English from the Health Survey for England confirmed the disparity indicated by the self-reported data. For example, 40% of Americans had levels of C-reactive protein in the high-risk range, compared with 30% of the English (PA significant health disparity remained after adjusting for differences in the current rates of obesity, smoking, and alcohol consumption between the two countries.

The study included only white men and women to avoid confounding with the special health problems of minority populations in the United States, the investigators explained.

The fact that the English government provides health care to all its citizens while the United States does not may contribute to the disparity, the authors said. "But it is equally important to recognize that health insurance can not be the central reason for the better health outcomes in England because the top socioeconomic tier of the U.S. population have close to universal access but their health outcomes are often worse than those of their English counterparts," the authors said.

"Two simple but powerful conclusions follow from our comparisons," the authors said. "First, Americans are much sicker than the English. Self-reports of disease are not deceiving us about the reality of the situation on one side of the Atlantic versus the other."

"Second, the socioeconomic status health gradient is also not a reporting mirage," they concluded. "Instead, the socioeconomic status health gradient appears with equal force in either self-reports or biological measures of health."

The study also indicated that there may be some important determinant of health that science doesn't understand yet, said James P. Smith, Ph.D., of the Rand Corporation in Santa Monica, Calif., and the lone American author on the study.

Future research may find one or more of the following factors to underlie the English-American health gap, Dr. Smith said:

Childhood disease. A growing body of research shows that heath conditions in childhood, and even prenatally, are an important cause of disease that may not appear for many decades. So far, there are not much data on differences in childhood health conditions in England versus America, but that is one avenue of research Dr. Smith and colleagues are exploring.

Obesity. Although the study adjusted for current levels of obesity in both countries, Americans entered the obesity epidemic far ahead of the English. In fact, the prevalence of obesity in England is just now reaching the U.S. rates of 15 years ago. The fact that more Americans have been obese for a longer amount of time may explain their poorer health. "But the English are narrowing the gap, and they may catch up," Dr. Smith said.

Stress. The American lifestyle is more stressful than the English, both at home and work. Although Americans benefit from their high-stress, "winner take all" approach to life in terms of better standard of living, "the stress may be taking a toll on adult health," Dr. Smith suggested.

Because Americans are in poorer health across a variety of disease categories, "there is probably no smoking gun," Dr. Smith said. "It will likely turn out to be a combination of different factors."

Reviewed by Zalman S. Agus, MD Emeritus Professor at the University of Pennsylvania School of Medicine

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